Registry-Managed Care Coordination and Education for Patients with Co-occurring Diabetes and Serious Mental Illness

Judith A. Cook
Jessica A. Jonikas
Pamela J. Steigman
Crystal M. Glover
Jane K. Burke-Miller
Joni Weidenaar
Sheila O'Neill
Debbie Pavick
Asma Jami
Charles J Santos
Peer-Reviewed Article
April 2021


An evidence-based intervention at a behavioral health home improved health outcomes for patients with co-occurring type 2 diabetes and serious mental illness.


Adults with serious mental illness are two to three times more likely to have diabetes than the general population, but many do not receive high-quality care or are not accurately diagnosed with diabetes. These comorbid disorders are associated with poor quality of life, low treatment adherence, frequent emergency department use, and high medical costs. This study sought to understand the effects of evidence-based intervention strategies — care coordination, use of electronic registries, and personalized patient education — on health outcomes for patients with co-occurring diabetes and serious mental illness in a behavioral health home.


A cohort of 179 patients with serious mental illness and diabetes mellitus type 2 had significant declines in glucose, lipid, and blood pressure levels related to their diabetes after the multicomponent care coordination intervention was introduced. Participating patients had substantially higher likelihood of completing optometry and podiatry referrals, which are important specialty appointments for diabetes patients.  


These findings suggest that an evidence-based care coordination intervention can improve health outcomes for individuals with diabetes and serious mental illness within a behavioral health home with co-located primary care. The components of this intervention — care coordination, electronic registries, and personalized diabetes education — may be strengthened by incorporating additional evidence-based practices such as smoking cessation. 

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